Provider Demographics
NPI:1326762972
Name:SODERMAN, LISA (RDH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SODERMAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8441 N P.11 DR
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-2654
Mailing Address - Country:US
Mailing Address - Phone:906-280-4857
Mailing Address - Fax:
Practice Address - Street 1:122 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9164
Practice Address - Country:US
Practice Address - Phone:517-740-7422
Practice Address - Fax:517-315-4918
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902013702124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist